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To complete your NYSPIA Surgeons Group ID card and placard, please provide the following:

Name and Good-Will A Member may not use their affiliation with NYSPIA or NYSPIA's name, contacts, work products, opportunities, or other property to further the Member's personal or outside activities, business, or employment. A Member may not use NYSPIA's name in such a way as to lend weight or prestige to a member’s sponsorship of a political party or cause, or in an endorsement of the products, services or causes of any outside company or organization. 2) Legislative Lobbying and Political Activities The NYSPIA name or logo may not be used for any legislative lobbying or political activities other than those activities undertaken by NYSPIA itself. 3) Publications Either the NYSPIA Executive Board or his designee must approve any publication by an Associate Member if it: a) Bears the NYSPIA name b) Pertains to the subject matter of NYSPIA's work c) Results from a communication to or by an employee of NYSPIA d) Is created through use of any NYSPIA facilities, equipment, or work project 4) Solicitation and Distribution Associate Members may not use NYSPIA property or work time to sell personal products or services or solicit funds.

I hereby apply to become a participating surgeon with the New York State Police Investigators Association (NYSPIA) Surgeons Group. Each of my practice locations, which I am affiliated with, will be identified in this agreement. I will accept the fees listed in NYSPIA member’s insurance schedules as payment for the medical services provided to active and retired members of NYSPIA, as well as their spouses and eligible children. I also agree to be available to the NYSPIA Board of Directors and Surgeons Group as a resource for my medical expertise and/or affiliations to assist in certain circumstances. I understand that the NYSPIA Executive Board of Directors reserves the right to terminate my participation in the Surgeons Group at any time. In the event, that I choose to terminate my membership in the NYSPIA Surgeons Group, I agree to notify your office in writing 30 days prior to the effective date of the decision. I understand that if either the NYSPIA Board of Directors or I decide to terminate this agreement, I will return all materials pertaining to the organization by mail which uses tracking information. I understand if my NYSPIA Surgeons shield, ID card, or vehicle placard is lost or stolen, I will immediately notify the NYSPIA office. I also understand that my NYSPIA Surgeons Group credentials and vehicle identification placard is non-transferrable and may only be used by the NYSPIA Surgeons Group member. I will adhere to all correspondence I receive from the organization. In the event, that I wish to advertise my status as a participating member of the NYSPIA Surgeons Group or use the NYSPIA Surgeons Group logo, I agree to submit such advertisement for approval to the NYSPIA Executive Board of Directors. The NYSPIA Executive Board or their representatives may conduct on-site visits and will investigate any grievance or complaint. I understand that this agreement does not infringe upon my freedom of choice to accept a patient, nor does it put any constraints or limitations on my best clinical judgment in treatment. I understand that the NYSPIA Surgeons Group Identification Card, Surgeon Shield, and Vehicle Identification Placard will not be used to violate or abuse any local, state, or federal laws including those of the NYS Vehicle and Traffic Law. I understand and accept that all applications are subject to a basic background check prior to membership approval. I understand that the initial NYSPIA Surgeons Group membership payment of $500.00 includes my first year of NYSPIA Surgeons Group membership dues and the initial application processing fee. I understand that subsequent dues will be billed yearly at $500.00 and are due by March 31st. The current year vehicle identification placard will be issued to me upon payment of the current year’s dues and the return of the prior year’s vehicle identification placard to the New York State Police Investigators Association office.